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San Joaquin County Environmental Healepartment <br /> DATE SISTER FILE RECORD INFORMATIONVFR" <br /> GREEN FORM <br /> / SITE MITIGATION& LOP <br /> $NAOEO REAS FOR EHDUSE O r OWNER ION /w '1 y <br /> �Y.1WER �T1 CASES SITE <br /> X319 ► UNIT IV <br /> iwNeRFIERNAME acErenfeFo[[OWING PROPERTYOWNER/NFoRMMnoa• CNEORIFOWNERCURaENnYONRyLEMMEHDD <br /> PROPERTY OWNER NAME <br /> Firs( Ml Lasi PHONENUMBER <br /> BUSINESS NAME <br /> !/ Gi O/JSD�GJ CL-�c C� / {�-pEYMILAODRE55 <br /> �i4 Vr <br /> Owner Home Addreaa <br /> city <br /> STATE Zip <br /> Owner Mailing Address <br /> Mailing Address City <br /> scala <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El <br /> FEO AGENCY❑ OTHER❑ <br /> STM MIMMATION_ENVIRONMENTAL AgnesNMENT ZC VOLUNTARY CLrAmur_WATER QUALITY_I/W PI►!UN!INV[NT TON_t,00_ <br /> FACILITY IO INVN A�rnuaTlD Fill N Aeelowa EMpL Yee LEAD AaeBcr:EHD WqC TSC—EPA <br /> ILI4, Q 8 <br /> FACILITY FILE CoAIPLETE7HEFOLIOWING 13USINESS/FACILITY/SITE/NFORmAr1oN: <br /> IS this a NEW Business LOCATION not reviousl r y <br /> P y regulated b the ENVIRONMENTAL HEALTH DEPARTMENT? vas ❑ No to <br /> Is this an EXISTING Business LOCATION but a NEW TYPE ofregUlated Business? YES ❑ No�S`I <br /> BUSINEssfFACILITYISITE NAME � . <br /> SrtE AooREss I <br /> SUITE# BUSINESSPHONE <br /> CITY <br /> STATE <br /> BOARD OF SUPERVISOR DISTRICT LOCATION---- <br /> Mailing Atldreva HO/FFEREA7frwn Fac/////(y Addrssa c^ 1 Altentlon:orCare Of(tspearseQ <br /> Melling Addreaa City <br /> ,�`STgjE ZIP r F� <br /> L71 .'•�1Jt/ ' oloo <br /> 91C CODE APNN � COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party IS different from Property Owner or Facility Operator idenbrft 012b 3 e. <br /> BUSINESS NAME Aha n:o,Care Of <br /> Melling Address <br /> PHOM <br /> CITY <br /> STATE ZIPp _ <br /> AccotLNrAnaRFRR for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ba G AND COMPIJANCE ACRNOwfEU(:'NLYi: 1,the undersigned Applicant,certify that I am the Owen,Operator,or AwhoNud Agent of this Business,and 1 acim ololge that W PLRtffr FYey, <br /> .0inf crew Emroeceided Ito uRGFs�lir.mmlit r and c.Es ct, anted with thio eperati it wile be billed m IMtifthe.ddress identified above u the ACTOrmTMDRFSS for tlm site f dsa certify that <br /> W information provided on Wu vppscetion u true and carraq and that W«gelated acdsitiea wiB for performed m adhSdance with W applicable SAN JOAQUIN COUNTY Ordi . Coda.&.,m <br /> Standards and STATE and/or FIDERAL Laws and Regulations. As the ondersigned owner,operator,or agent of the property IMated at the shave facility/siftaddress,I hereby authorize the es of <br /> any and LI rmcfts and—cir. menml assevmm <br /> ent infnredon to SAN JOAQUIN COUNTY EM'URONhIFI T.AL HEALTW'DEP.ARTNfENT At enoD as it Is ac.ilAbla vad at the same time it is <br /> Provided to III my repzvrmative - <br /> APPLICANTNAME(PLEASEPRINT) e �����_$ 112+ `---t 0✓/cA.� SIGNATTIRE—�' � i �'� % <br /> ITLE - TAX ID p <br /> Approved By ✓ OeM — - <br /> Accounang Off a Pracesaing Completed By <br /> SITE MITIGATION AMOUNTTePAID ' DATE OF PAYMENT PAYME'NTT/YPE RECEIPT# CHE Ra RE IVED BY WoRX PLAN PE <br /> FEE: V <br /> II '•� I 5e •j,'1-II V �IY <br />